This study showed that disabled older patients who received multi-disciplinary PCDIR maintained a statistically and clinically significant higher level of independence from end of rehabilitation until 18 months afterwards, spent fewer days in short-term nursing homes and did not increase the institutional residence rate, compared to patients who received PCNHR. The rehabilitation and care costs of PCDIR were substantially lower.
Irrespective of the type of rehabilitation, cognitive status was a predictor of both the level of independence and the number of short-term days in nursing homes. This is consistent with our previous findings at end of and three months after the rehabilitation
. According to our experience the ability of initiative and to take instructions were the cognitive features of greatest importance for successful rehabilitation. Several studies identify cognitive status as a predictor of rehabilitation outcomes
Due to the disability of the study population, we expected that the institutional residence rate at 18 months follow-up would be higher than in the general Norwegian population at the same age. However, while 9.8% of the PCDIR and 15.6% of the PCNHR patients ≥80 years lived in nursing homes, 14.3% of the general Norwegian population of the same age group resided in nursing homes in 2007
. Our data indicate that PCDIR, if adopted on a broader scale, may reduce the number of Norwegians ≥80 years living in nursing homes (in 2007 n=31.000) by several thousands.
The one year mortality of the total study population was higher than in the general Norwegian population at the same age, 9.6% versus 6%, respectively
. Mortality rates reported after post-acute rehabilitation of older people are about 20%
[29, 30]. Only half of the patients in our study were in post-acute rehabilitation, which may explain some of the difference. Furthermore, the major causes of death in post-acute rehabilitation and care studies are cardiovascular, infectious and malignant diseases. Only a few patients with these diagnoses were included in our study
. Due to their higher ADL levels, we expected the PCDIR patients to have a better survival than the PCNHR patients. Surprisingly, there was a not statistically significant tendency towards the opposite. This may be explained by the higher morbidity as shown by more days in hospital.
The PCDIR intervention in this study was both more effective and less expensive compared to the PCNHR, thus meeting the criteria for a preferred strategy
. In such cases the health-care decisions are obvious and calculation of a cost-effective ratio is not necessary. The main reasons for the lower costs of the PCDIR were the shorter rehabilitation stay and the lower at-home care needs compared to the PCNHR. The costs of medication, transportation and outpatient physician and physiotherapy visits were not recorded, but we could not give any reasons that these costs would influence the cost differences in our study. The average total costs per patient were 1.6 times higher in PCNHR during 18 months follow-up. However, if further survival time is taken into account, the cost differences might be even higher. The remaining life time of 82 years old Norwegians is about seven years (men: six years, women: eight years)
A limitation to the study was the non-randomized design. We wanted to perform a study of the “real-life health care”, and a study of level 2 design was our nearest option to achieve more knowledge about this important and poorly investigated field. The first author worked as a GP in the rehabilitation centre when the PCDIR patients were recruited, which could have introduced a bias. She did the general clinical evaluation of the patients, but was not involved in the training of the patients and did none of the SI scores. Methodical weaknesses have been thoroughly discussed in a previous paper
. On the other hand, patient features likely to influence the outcomes were not different in the two rehabilitation models [Table
2, and all participants were considered to have a rehabilitation potential, which was assessed in the same way in the two models. Most of the procedures and decisions were standardized.
The measurement scales used in this study are proven to be valid, reliable and sensitive to change over time. SI is not widely used internationally, but it is the commonly used ADL-scale in primary care in the study county. The inter-item consistency between the internationally commonly used FIM and SI is high for many items, even if differences also exist
. We believe that when clinically significant improvements in different ADL-scales are defined, it is possible to compare different ADL-scales in terms of level of independence.
We have not found other studies evaluating the long-term outcomes of a dedicated primary health care based rehabilitation similar to the present model. However, both intermediate and specialized multi-disciplinary, inpatient rehabilitation of older people have shown a benefit in long-term (3-12months) outcomes compared to standard community or general hospital care
[8, 29, 33, 34]. Studies of these rehabilitation programmes for older people in general-, orthopedic- and stroke rehabilitation report higher long-term levels of independence
[8, 29, 33–35] and lower long-term levels of institutionalization
[8, 33, 35] and mortality
[8, 29, 35, 36]. More intensive exercise increases the success of hip-fracture programmes
Cost-saving effects of different rehabilitation strategies are unclear, and it is difficult to compare costs across countries since both the reimbursement systems, delivery agreements and the price levels differ. Norwegian community hospitals are likely to provide health care at lower costs than alternative models of care, like general hospitals, nursing homes and at-home care
. A community hospital in the Netherlands was also shown to be a cost-saving alternative for older patients in need of intermediate medical and nursing home care between hospital and at-home care
. The lower one year costs of a Norwegian post-acute community hospital compared to a general hospital might be out-weighed by a higher proportion of the patients residing in a nursing home at follow-up
. Sub-acute nursing homes were more effective than traditional nursing homes in returning patients aged ≥65years with stroke to the community, but the Medicare costs were greater
The PCDIR model includes the main features of the WHO rehabilitation cycle
. We believe that rehabilitation programmes which adhere to this cycle are more likely to be beneficial